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Incidental Paratracheal Air Cyst in Papillary Thyroid Cancer Patient: a Case Report

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Incidental Paratracheal Air Cyst in Papillary Thyroid Cancer Patient: a Case Report 2339 Case Report Incidental paratracheal air cyst in papillary thyroid cancer patient: a case report Min Jhi Kim^, Hera Jung, Cheong Soo Park Department of Surgery, CHA Ilsan Medical Center, Cha University School of Medicine, Goyang-si, Gyeonggi-do, South Korea Correspondence to: Cheong Soo Park, MD, PhD. Department of Surgery, CHA Ilsan Medical Center, Cha University School of Medicine, 1205, Jungang-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, South Korea. Email: [email protected]. Abstract: Paratracheal air cyst (PTAC) is a collection of air in the right posterior side of the trachea with an uncertain etiology. We report a papillary thyroid cancer patient with a PTAC that was removed during thyroid cancer surgery. A 68-year-old woman was diagnosed with right papillary thyroid cancer with suspicion of central lymph node metastasis. She had a history of hypertension and a rear-end collision car accident 20 years prior. On computed tomography, an ovoid cyst was incidentally found in the paratracheal region at the thoracic inlet level. Emphysematous lung with an obstructive lung defect was noted without any symptoms. Bilateral total thyroidectomy with ipsilateral central compartment neck dissection was indicated for the patient. During surgery, removal of the cyst was inevitable for complete central neck dissection. Histopathologic analysis revealed an etiology of tracheal mucus sprouting through weak trachea points. No postoperative complications occurred. The patient continued on levothyroxine medication without further radioactive iodine therapy. After 6 months, follow-up ultrasound showed no evidence of recurrence. We hypothesized that obstructive lung disease with impaired lung function or trauma history might have contributed to the development of PTAC. Future studies are needed to determine if PTACs have any association with obstructive lung disease or trauma. Keywords: Paratracheal air cyst (PTAC); trachea; computed tomography (CT); thyroid cancer; case report Submitted Mar 04, 2021. Accepted for publication Jun 03, 2021. doi: 10.21037/gs-21-139 View this article at: https://dx.doi.org/10.21037/gs-21-139 Introduction an association between PTACs and other pulmonary abnormalities, including congenital respiratory tract Paratracheal air cysts (PTACs) are collections of air adjacent to abnormalities, obstructive lung diseases, emphysema, upper the trachea. The lesions are often asymptomatic and detected lung fibrosis, chronic cough, and trauma in the thorax. incidentally in routine imaging, such as neck or thoracic computed tomography (CT) scans. The prevalence of these However, few studies have determined these relationships lesions has been reported to be 0.3% to 3.7% (1,2). PTACs (1,2,5-9). Similar to tracheal diverticula, PTAC can cause are usually observed on the right side of the trachea at the level a variety of chronic and recurrent aerodigestive tract of the thoracic inlet. Communication of these lesions with the symptoms (10). Differential diagnosis of PTAC includes trachea is noted in fewer than 10% of cases (1). tracheal diverticulum, Zenker’s diverticulum, pharyngocele, The pathogenesis of PTAC is diverse, and such lesions laryngocele, pneumomediastinum, apical lung hernia, apical are described in both congenital and acquired conditions. A paraseptal lung bulb, and bullae (1,2,11). few studies have considered PTACs and tracheal diverticula Typically, PTACs are asymptomatic, but symptomatic as similar entities (1,3,4). A previous study reported PTACs require treatment. Nonsurgical and conservative ^ ORCID: 0000-0002-7791-2994. © Gland Surgery. All rights reserved. Gland Surg 2021;10(7):2334-2339 | https://dx.doi.org/10.21037/gs-21-139 Gland Surgery, Vol 10, No 7 July 2021 2335 A B C T T C Figure 1 Incidental paratracheal air cyst in a 68-year-old female with old healed pulmonary tuberculosis. The axial computed tomography (CT) (A) and coronal CT (B) images show a paratracheal air cyst in the right posterolateral aspect of the trachea at the level of the thoracic inlet. Diffuse bronchiectasis was noted on additional thin section CT images. T, trachea; C, paratracheal cyst. management, such as administration of antibiotics, defined, right thyroid nodule measuring approximately mucolytics, and bronchodilators, are used in initial treatment. 2 cm. There was no cervical lymphadenopathy. Laboratory However, in cases in with critical or recurrent symptoms such serum tests including complete blood count, electrolytes, and as compression symptoms (dyspnea, dysphagia, hoarseness), thyroid function were normal. Ultrasound of the neck showed recurrent infections, or chronic cough, surgical intervention a diffusely enlarged thyroid with coarse heterogeneous is recommended (11,12). parenchyma. Multiple, conglomerated, irregular, hypoechoic, In this report, we present a case of asymptomatic nodular lesions were seen in the right mid-lower thyroid. PTAC that was incidentally found in a patient with The lesions measured 2.1 cm in longest diameter on the papillary thyroid carcinoma (PTC). We report the first longitudinal view. Enlarged paratracheal lymph nodes (LNs) case of asymptomatic PTAC that was surgically removed. with a round shape, focal cortical hypertrophy, and 8 mm in Surgical resection enabled us to perform histopathological maximum diameter were identified. examination, which provided insight into the etiology Thoracocervical 64-slice CT scan with intravenous of PTAC, and to review clinical factors that might be contrast showed an approximately 2-cm-sized, ill- associated with its etiology. We present the following case defined, low-density lesion in the right thyroid with in accordance with the CARE reporting checklist (available multiple enlarged LNs in the right paratracheal and at https://dx.doi.org/10.21037/gs-21-139). upper mediastinal region. None of the radiologic findings suggested lateral neck metastasis or pulmonary metastasis. A large ovoid cyst was found incidentally in the right Case presentation posterolateral wall of the trachea at the thoracic inlet Patient level, beneath the collection of enlarged paratracheal LNs. The cyst measured 2.3 cm in longest diameter. Diffuse A 68-year-old woman was referred to our hospital after bronchiectasis was noted in both lungs. Fibrocalcified diagnosis of right thyroid nodule that measured 2 cm and lesions of presumed tuberculous origin (old healed was suspicious for PTC by fine needle aspiration biopsy tuberculosis) were seen in the left upper lobe (Figure 1A,B). (Bethesda category V). She complained of a protruding Pulmonary function test revealed a moderate obstructive neck mass causing neck swelling, neck discomfort, and lung defect with decreased forced expiratory volume in one sore throat. The patient had a history of hypertension second (FEV1) of 73% (1.16/1.58) and a FEV1/expiratory and was taking angiotensin II receptor blockers. She was forced vital capacity (FVC) ratio of 68%. a non-smoker and had no respiratory symptoms. She had also experienced a rear-end collision car accident without Surgery physical injury 20 years prior. Physical examination of the neck revealed a hard, ill- Bilateral total thyroidectomy under general anesthesia © Gland Surgery. All rights reserved. Gland Surg 2021;10(7):2334-2339 | https://dx.doi.org/10.21037/gs-21-139 2336 Kim et al. PTAC with papillary thyroid cancer A B C D Figure 2 Histopathological features of paratracheal air cyst. Hematoxylin and eosin (H&E) staining. (A) Cystic lesion with thin-walled epithelium (×1.25); (B) ciliated epithelium with mucin-containing goblet cells (×400); (C) Periodic acid-Schiff (PAS) stain highlights cytoplasmic mucin (×400); (D) magnified submucosal glands below the epithelium (×400). was indicated for the patient due to the following Pathology conditions: age >55 years, cancer lesion >2 cm in size, Histopathological examination of the right thyroid gland and enlarged central LNs with suspicious features. After revealed an ill-defined infiltrative tumor measuring 2.1 cm right hemithyroidectomy, ipsilateral central compartment × 1.9 cm that was confirmed to be oncocytic variant PTC. neck dissection (CCND) was conducted. The procedure There was no extrathyroidal extension, lymphatic invasion, comprised level VI LNs (prelaryngeal, pretracheal, and paratracheal LNs) and level VII LNs (upper mediastinal or blood vessel invasion by the tumor. Marked chronic LNs). As we proceeded with paratracheal LN dissection, lymphocytic thyroiditis was observed in both glands. No the upper part of an air cyst was found adjacent to the metastasis was found among 15 level VI LNs and 12 level trachea in the right paratracheal region at the thoracic inlet VII LNs (0/27). level. The mass was ovoid and cystic, surrounded by a thin The thin-walled cystic mass resected from the wall, and measured approximately 1.3 cm in diameter. For paratracheal area was inspected. On gross examination, the further LN dissection at level VII, removal of the PTAC resected specimen consisted of a thin-walled cystic mass was inevitable. Because of the considerable volume of the measuring 1.4 cm (Figure 2A). No specific contents or cyst, a 21-gauge syringe needle was used to aspirate it to solid portion was identified. The microscopic findings with reduce its volume; 3 mL of air was aspirated. The mass hematoxylin and eosin (H&E) staining revealed that the was excised, and a subsequent level VII LN dissection and cyst was lined by ciliated columnar epithelium with periodic left hemithyroidectomy were performed sequentially. The
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